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Parathyroid Hormone Analogue (Anabolic) Pregnancy: Contraindicated — not indicated in premenopausal women unless severe osteoporosis under specialist supervision; insufficient pregnancy data.

Teriparatide

Brand names: Forsteo, Terrosa, Movymia

Adult dose

Dose: 20 micrograms SC once daily
Route: Subcutaneous injection (thigh or abdomen)
Frequency: Once daily
Max: 20 micrograms OD; maximum cumulative duration 24 months (lifetime limit)
Recombinant human PTH (1–34) — anabolic agent (builds new bone), in contrast to antiresorptive bisphosphonates/denosumab. Reserved for severe osteoporosis (T-score ≤-3.0 or prior fragility fracture on antiresorptive therapy). 24-month lifetime limit due to osteosarcoma signal in rats (not demonstrated in humans but precautionary limit maintained). After completing course, must transition to antiresorptive therapy to preserve bone gain.

Paediatric dose

Route: Subcutaneous injection
Frequency: Once daily
Max: Not applicable
Not licensed under 18 years and contraindicated in open epiphyses. Seek specialist opinion.

Dose adjustments

Renal

eGFR <30: avoid — risk of hypercalcaemia; also limited data.

Hepatic

No specific dose adjustment — limited hepatic metabolism.

Clinical pearls

  • NICE TA161: teriparatide only recommended for severe osteoporosis (T-score ≤-3.0) in postmenopausal women ≥65 years with ≥2 fragility fractures and when bisphosphonates contraindicated or not tolerated
  • After completing 24-month course: bone gain is rapidly lost without follow-on antiresorptive — transition to alendronate or denosumab promptly
  • Inject at bedtime if orthostatic hypotension is an issue — reduces fall risk from dizziness
  • First injection should be given in clinic — observe for 30 minutes for orthostatic hypotension

Contraindications

  • Open epiphyses (children/adolescents)
  • Pre-existing hypercalcaemia
  • Paget's disease of bone or unexplained elevated ALP
  • Prior radiation to skeleton
  • Bone metastases or skeletal malignancy
  • eGFR <30
  • Hypersensitivity to teriparatide

Side effects

  • Hypercalcaemia (transient, post-injection)
  • Hypotension (particularly 4–6h post-injection — sit/lie down after administration)
  • Dizziness, nausea
  • Muscle cramps
  • Palpitations
  • Injection site reactions

Monitoring

  • Serum calcium (1–3 months after starting)
  • ALP (if unexplained rise — investigate)
  • DEXA scan after completing 24-month course
  • Symptom review (orthostatic hypotension, palpitations)

Reference: BNFc; BNF 90; NICE TA161; NICE TA160; Forteo SPC. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

Pathways